The Relationship Between Functional Motor Status and Self-evaluation in Individuals With Cerebral Palsy: A Systematic Review

Cerebral palsy (CP) is a common pediatric disorder that results in a wide range of motor and functional problems that impose mobility limitations, decrease the quality of movement, negatively affect physical activity participation, self-care, and academic performance, and ultimately result in social isolation and negative self-evaluation. Despite abundant evidence of motor function, very few studies investigated all aspects of self-evaluation or described the relationship between motor function and self in individuals with CP. The present study aimed at investigating the relationship between functional motor status and self-evaluation in individuals with CP. A systematic search was performed in six electronic databases (PubMed, Scopus, ProQuest, OTseeker, Web of Sciences, and Google Scholar) for English language articles from any date to May 2019. Screening, selection, and quality assessment were conducted by two authors independently. All studies recruiting individuals with CP and using functional motor status and self-evaluation tests were included. The AXIS checklist was used for the quality assessment of included studies. As all data sources were generated by published studies, ethical approval was not applicable to the present study. Seven articles met the inclusion criteria. These studies investigated the relationship between functional motor status and self-esteem and self-concept. Based on the AXIS, three articles were identified as high quality and four as low quality. The result of the present review showed that there was no relationship between self-concept and functional motor status in individuals with CP, while there was a significant relationship between self-esteem and functional motor status. More studies are required to shed light on other aspects of self and relationship of self-evaluation with motor function in individuals with CP.


Introduction
Cerebral palsy (CP), a non-progressive disorder, is the outcome of damage to a developing brain.
It leads to upper motor neuron lesion signs, such as spasticity, increased reflexes, dysarthria, dysphagia, poor motor control, abnormal posture, and neuropsychological dysfunctions (1). The prevalence of CP in Iran is estimated as 2 cases per 1000 live births (2). Neurological problems cause motor and process dysfunctions and engage all aspects of the activities of daily living (ADL), such as self-care, mobility, participation, and social and communication performance (3,4).
About 55% of individuals with CP are estimated to have normal intellectual ability and can be classified as a high level of gross motor function (5). Although such individuals have a good perception of social skills (6), they have a set of abnormalities, for instance abnormal gait (7), strabismus (8), scoliosis (9), drooling (10), and low body composition (11). They are thought to be at increased risk of impaired self-image and negative bodily experiences (12). Individuals with CP are exposed to different peer perceptions, which eventually lead to social isolation (13). Therefore, disability stems from social exclusion and cultural obstacles (14).
Although occupational and physical therapists should pay attention to motor problems, most specific psychosocial aspects, such as self, remain ambiguous. The effects of motor problems on self should be considered in occupational therapy interventions for individuals with CP. Cara and MacRae stated that "the construction of self is helpful for understanding the potential psychosocial impact of physically disabling conditions" (15). Individuals with CP should get along with a disabled body that often experiences fatigue and fails to make the best use of time or resources (12,16). Self-evaluation can be a critical element in awareness of deficiencies and competencies. There are several definitions for this concept; for instance, Taylor et al., defined selfevaluations as "a fundamental task of self-regulation.
Without feedback on where one stands and how is doing concerning his goals, effective self-regulation is virtually impossible" (17). Brown et al., stated that "We prefer to call self-evaluations or selfappraisals as they refer to the way people evaluate or appraise their specific abilities and personality characteristics" (18). The self-evaluation process arises from social comparison, somehow peer's overall performance or children's tendencies and competencies (19,20). More generally, authorities perceived self-evaluation in diverse elements, such as self-concept, self-esteem, self-efficacy, expectations of success, self-confidence, self-competency, selfcenteredness, self-acceptance, self-satisfaction, selfappraisal, self-worth, self-ideal, sense of adequacy, personal efficacy, sense of competence, congruence, ego, and ego-strength (21,22).
Occupational therapists make use of the clientcentered approach in assessment and goals setting procedures (1). The theory of the client-centered approach originates from self-constructor. Self and factors associated with self-evaluation are taken into consideration as a prime precept in using the client-centered approach to identify the client's precedence and established unique therapeutic goals. Individuals with CP have lower self-evaluation than healthy controls. They represent problems in scholastic competence, social acceptance, and athletic competence (23).
Consequently, therapists should pay attention to the feelings of physically disabled individuals, including their romantic appeal, educational competence, and social acceptance (24).
Iran J Child Neurol. Summer 2021 Vol. 15 No. 3 There are several systematic reviews and metaanalyses on the self-concept of individuals with CP.
Self-concept in children with any type of chronic illnesses (i e, asthma, CP, diabetes, epilepsy, and juvenile arthritis) was explored in a meta-analysis by Ferro and Boyle (25). Their study showed that the risk of lower self-concept slightly increased in adolescents with a chronic illness as compared with typical controls. Similar findings in a systematic review by Nora Shields et al., showed that children with CP rated lower self-concept in comparison with children with typical development (26).
In another meta-analysis by Nicole Dunn et al., parents and teacher's perception of children versus children's self-concept was investigated. The results showed that children with CP perceived their abilities relatively higher in comparison with that of the parents. Another meta-analysis of findings indicated no differences between the teacher and child's perception of rating his abilities (27).

Materials & Methods
Since all data sources were generated by published studies in peer-reviewed journals, ethical approval for the systematic review design was not applicable (28). Leary and Tangney investigated all keywords around "self" and identified more than 66 separate terms (29) that are presented in Table 1. Also, the main terms related to self-evaluation were explored in the MESH.
Several electronic databases, including PubMed, Scopus, ProQuest, OTseeker, Web of Sciences, and Google Scholar (as a search engine), were searched. The study used self-related terms ( Table   1) combined with "cerebral palsy". The electronic search was limited to English language articles from the beginning to May 2019. All findings were transferred to the EndNote software, and duplicates were eliminated. Finally, the overall lists of articles were prepared for the review and selection process.

Inclusion and exclusion criteria
Articles were considered eligible if they met the following criteria:  (30). Since this tool is a subjective measurement, a quality score of ≥70% was considered high and <70% low methodological qualities (31).

Study selection
In the selection process, 67 keywords were considered for search strategy design; therefore, long lists of findings, consisting of 2783 articles, were attained after the first administration of keywords. After reviewing titles/abstracts and employing inclusion/exclusion criteria, seven articles were selected as final articles (see Figure 1).

Studies characteristics
Study design, number of participants, age, type of CP, functional motor status outcome measures, self-evaluation outcome measures, findings sorted by authors, and years of publication are provided in Table 2.

Design and quality of studies
Inter-rater agreement was 83% between the first and second reviewers across rating quality of studies.
The details of quality assessments are presented in Table 3. Throughout all the studies, the goals were well-defined. Three studies recruited healthy subjects for the control group (34,36,37), and therefore, they did not acquire the scores of study design items. Four studies provided information about the number of non-responder participants and their demographical characteristics (33)(34)(35)38); three studies did not clarify non-responder participants (32,36,37), and three studies did not represent sufficient information about the validity or reliability of outcome measures (35-37).

Participants
Most participants were within the age range of 9.3±1.8 to 17.6 years. In two studies, participants were adults with a mean age of 41.3 and 26±6 years. The number of participants ranged from 16 to 108. function measure (GMFM) (38), were utilized to measure functional motor status.

Self-evaluation measures
Included studies measured only two self-related areas, including self-concept and self-esteem (self-perception). Definition of terms and related subscales are presented in Table 4

Self-concept
Three studies investigated the cross sectional relationship between gross motor function and selfconcept. All studies assessed patients with mild to severe CP and found that GMFCS E&R was not related to self-concept (33,35,36). Cheong   Desired/Undesired Self Self-blame Self-handicapping Ego Self-care Self-help Ego defense Self-categorization Self-identification Ego extension Self-completion Self-identity Ego ideal Self-complexity Self-image Ego identity Self-concept Self-management Ego integrity Self-confidence Self-monitoring Ego strength Self-conscious emotions Self-origination Ego threat Self-consciousness Self-perception Feared self Self-control Self-preservation Future/past self Self-criticism Self-presentation Ideal self Self-deception Self-protection Identity Self-defeating behavior Self-reference Identity orientation Self-definition Self-regard Ought/should self Self-development Self-regulation Possible selves Self-disclosure Self-reliance Self-acceptance Self-discrepancy Self-schema Self-actualization Self-doubt Self-silencing Self-affirmation Self-efficacy Self-talk Self-appraisal Self-enhancement Self-trust Self-assessment Self-esteem Self-verification Self-awareness Self-evaluation Self-worth  I=36  II=8  III=5  IV=1  MACS:  I=15  II=25  III=8  IV=2 MACS, GMFCS-E&R myTREEHOUSE self-concept assessment Self-concept There was not a significant relationship between personal performance perspective scores* and personal concern scores**, and GMFCS-E&R and MACS.    Table 4. Definition of terms Term Explanation Self-concept "The way an individual perceives himself and his behavior, and his opinion of how others view him" (41).

Discussion
The current systematic review aimed at synthesizing the previous evidence of a relationship between functional motor status and self-evaluation in individuals with CP. The results of the current review showed no relationship between self-concept and functional motor status in individuals with CP, while there was a significant relationship between selfesteem and motor function, which seems to be due to the difference between these two aspects. Although the terms self-concept and self-esteem are often used interchangeably, they represent different but related constructs.
The Therefore, future studies need to pay more attention to other self-related aspects of people with CP.

Strengths and limitations
As with any study, the current study had some strengths and limitations. study results should be interpreted with caution.